CMS Pub. 100-04, ch. 32, § 190.3

and Claim Adjustment Reason Code

(Rev.10881; Issued: 08-06-2021; Effective: 09-07-2021; Implementation: 09-07- 2021)

Contractors shall continue to use the appropriate existing messages that they have in place when denying

claims submitted that do not meet the Medicare coverage criteria for extracorporeal photopheresis.

Medicare coverage for extracorporeal photopheresis is restricted to the inpatient or outpatient hospital

settings specifically for BOS, and not for the other covered diagnosis (including chronic graft versus host

disease) which remain covered in the hospital inpatient, hospital outpatient, and non-facility (physician-directed clinic or office settings) settings.

Contractors shall deny claims for extracorporeal photopheresis for BOS when the service is not rendered to

an inpatient or outpatient of a hospital, including critical access hospitals using the following codes:

• Claim Adjustment Reason Code (CARC) 96 – Non-covered charge(s). At least one Remark Code

must be provided (may be comprised of either the NCPDP Reject Reason [sic] Code, or Remittance

Advice Remark Code that is not an ALERT.) NOTE: Refer to the 835 Healthcare Policy

Identification Segment (loop 2110 Service Payment Information REF), if present.

• CARC 171 – Payment is denied when performed/billed by this type of provider in this type of

facility. NOTE: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service

Payment Information REF), if present.

• Medicare Summary Notice 16.2 - This service cannot be paid when provided in this

location/facility." Spanish translation: "Este servicio no se puede pagar cuando es suministrado en

esta sitio/facilidad. (Include either MSN 36.1 or 36.2 dependent on liability.)

• Remittance Advice Remark Code (RARC) N428 – Not covered when performed in

this place of service. (A/MACs only)

B. Group Code CO (Contractual Obligations) or PR (Patient Responsibility) dependent

on liability.

Contractors shall return to provider/ return as unprocessable claims for BOS containing HCPCS procedure

code 36522 along with one of the allowable ICD-10 codes if the claim is missing diagnosis code Z00.6 (as

primary/secondary diagnosis, institutional only), condition code 30 (institutional claims only), clinical trial

modifier Q0/Q1, and value code D4 with an 8-digit clinical trial identifier number (A/MACs only). Use the

following messages:

When diagnosis code Z00.6 is missing, use:

• CARC 16 “Claim/service lacks information or has submission/billing error(s).” and

• RARC M76, “Missing/incomplete/invalid diagnosis or condition.”

When Condition Code 30 is missing, use CARC 16 and

• RARC M44 “Missing/incomplete/invalid condition code.”

When Clinical Trial modifier Q0/Q1 is missing, use CARC 16 and

• RARC N822, “Missing procedure modifier(s).”

When Clinical Trial Number is missing, use CARC 16 and

• RARC MA50, “Missing/incomplete/invalid Investigational Device Exemption number or Clinical

Trial number.”

When Value Code D4 is missing, use CARC 16 and

• RARC M49, “Missing/incomplete/invalid value code(s) or amount(s).”